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s s,- Pip 'QUALITY TESTING OF UNDERGROUND TANKS'ATAFFORDABLERATES' Post Oce Box 36 Thornton, Ca. 95686 (209) 794-0102 FAX 794-0112 General Information Facility Name: kala Bldg.No.: Site Address: 19 75E ' S r City: X ,e 2f Zip: Facility Contact Person: Contact Phone No.: ( ) a 3` Make/Model of Monitoring System:_ o 8 r_ Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the apgMriate boxes to indicate gecific a ui ment' ected/serviced: T ID: A5'1 e Tank ID: In-Tank Gauging Probe. Model:L7 '► ❑ In-Tank Gauging Probe. Model: EfAnnular Space or Vault Sensor. Model: E 5; ❑ Annular Space or Vault Sensor. Model: U"Piping Sump/Trench Sensor(s). Model:-"— ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑�,Flectronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Ef Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s eci equipment a and model in Section E on Pae 2). ❑ Other(s eci ui ment a and model in Section E on Pae 2). Tank ID: Tank ID• ❑ In-Tank Gauging Probe. Model: ❑ In-Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: b ❑ Other(s eci ui ment=e and model in Section E on Pae 2). ❑ Other(s eci ui ment type and model in Section E on Paa 2). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s).. ❑Dis enser Containment Float(s)and Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment: For any equipment capable of generating such reports,I have also attached i copy of the report;(check all that apply): ❑System set-up ❑Alarm histery report Technician Name(print): .Yle e) Signature: Certification No.: License. No.:i Page 1 of 3 03/01 Monitoring System Certification